16: Hospital Care

Almost 20% of people 65 years of age or older are hospitalized each year in the United States, a rate nearly 4 times that of the general population. Those 65 years of age or older account for approximately 38% of all hospital admissions, 47% of inpatient care days, and 45% of hospital expenditures. Older adults account for 74% of all in-hospital deaths and have more discharges to places other than home. Many are frail and experience disability and comorbid illnesses. Because of their medical complexity, older patients typically require services from multiple health care providers, most of whom have no formal training in geriatric medicine.

Hospitalization is a critical time for older patients, and heralds a period of high risk that extends beyond discharge, especially for the frail and the very old. The landmark Harvard Medical Practice Study (HMPS) demonstrated that adverse events occured in approximately 4% of hospitalizations. Because older adults make up almost half of all inpatient care days, they are at a disproportionate risk for hospital adverse events. For example, in the HMPS, patients age 65 years or older accounted for only 27% of the hospitalized population, but experienced 43% of all adverse events.

Hospitalization-associated disability is a common and feared complication of hospitalization for older adults. New activities of daily living (ADL) deficits occur in as many as 30% of patients 70 years of age or older who are admitted to an acute care hospital from the community, and hospitalization accounts for approximately 50% of new disability that community-dwelling older adults experience. Hospital processes of care and environment contribute both to failure to recover from functional loss that occurred before admission as well as new decline during the hospitalization (Figure 16–1).

There are a number of factors that contribute to the hostile environment of hospitals. Bed rest and low mobility are major contributors to functional decline. Even short periods of bed rest can result in significant loss of muscle mass and strength in older adults. There are many reasons that bed rest occurs even when not explicitly written for, including crowded hospital rooms; beds that are difficult to transfer in and out of either because of height or rails; hallways that are cluttered and polished, slick floors that present a hazard to an older patient trying to navigate in unfamiliar territory; and lack of adaptive devices that the patient may use at home to overcome deficiencies such as raised toilet seats or shower chairs. Patients are frequently attached to peripheral devices such as IV poles, oxygen tubing, urinary catheters, cardiac monitors or other tethers that inhibit mobility. Concerns about falls often result in inappropriate confinement to bed. Studies show that most patients will not ambulate on their own unless explicitly told to do so, yet clinicians rarely discuss exercise in the hospital with patients. In addition, older adults may experience enforced dependence when nursing staff and concerned families assist patients with ADLs regardless of the patient’s underlying ability to perform independently. Undernutrition is another factor that contributes to functional decline. Up to a quarter of hospitalized older adults receive less than 50% of required daily protein-energy intake either because of nothing by mouth (NPO) status, poor appetite, or eating an unfamiliar and unappetizing diet. Older adults are also at high risk for adverse drug events as a result of more comorbidities and polypharmacy, with approximately 10% to 15% experiencing an in-house adverse drug event. Singly or in combination, all of these factors can result in disability, falls, delirium, depression, pressure ulcers, bowel and bladder dysfunction, and increase the risk for the loss of independence and need for institutional rehabilitation.

Despite this grim situation, hospital care can be improved for older patients. Focused efforts have improved treatment of specific conditions such as myocardial infarction, congestive heart failure, and pneumonia. Moreover, reengineering the microsystem of care (eg, how care is delivered on a hospital ward or how hospital care is linked to posthospital care) has been shown to improve outcomes in this vulnerable population.

A number of interventions that target older patients who are at high risk for hospital-associated complications have been developed to address the challenges above. Successful care models focus on goals of care, comprehensive geriatric assessment, and interprofessional, team-based care. Attention is given to the physical environment, processes of care, and prevention of specific hospital associated complications that are common in vulnerable older patients. These models include Acute Care for Elders (ACE) units, the Hospital Elder Life Program (HELP), clinical pathways and care maps, and geriatrician–surgical comanagement.

ACE units were developed with the explicit goal to prevent functional decline and improve the quality of care for older adults during acute hospitalization. ACE units utilize comprehensive geriatric assessment and interprofessional team-based care to align care plans with patient goals and to prevent common complications of hospitalization, such as deconditioning, cognitive and nutrition decline, and polypharmacy, rather than correcting them after they develop. ACE units include a prepared environment that promotes mobility (raised toilet seats, low beds, carpeted hallways, handrails, and assistive devices) and orientation (clocks, calendars, rooms for group meals to increase socialization). Nursing protocols are deployed to promote continence, enhance sleep via nonpharmacologic means, maintain good nutrition, promote skin integrity, and provide frequent reorientation and inclusion of patients in plans of care. Emphasis is placed on discharge planning early in hospitalization with the explicit goal of returning home to independent living. In addition, medical care plans are reviewed to prevent polypharmacy as well as minimize unnecessary procedures. In randomized trials, ACE units have been shown to improve or maintain ADLs, decrease discharges to long-term care, increase provider and patient satisfaction, and, in some studies, showed decreased length of stay and decreased cost even after accounting for capital costs of unit modification.

HELP is another multicomponent intervention. It was developed to prevent delirium in older hospitalized adults using hospital volunteers implementing its protocols on general medical wards throughout the hospital. The interventions were aimed at patients who were at medium to high risk for developing delirium based on predetermined risk factors and were aimed to address the specific risk factors of individual patients. For example, sleep deprivation can lead to delirium and measures were initiated to promote quiet environments (turning beepers to vibrate and keeping hallways quiet) and nonpharmacologic sleep protocols (warm milk and back rub for insomnia). Other risk factors addressed included immobility, visual and hearing impairment, cognitive impairment, and dehydration. Randomized trials showed a reduction in incident delirium of one-third compared to control groups, as well as improvements in duration and severity. Similar results have been obtained on nonmedicine services such as reductions in delirium following implementation of protocols in hip fracture patients on surgical wards.

Clinical pathways or care maps are methods for improving standardization of care across various providers and units. Clinical pathways or care maps are problem-specific management plans that delineate standardized key steps along an optimal timeline to achieve specific goals. For example, a care map for total knee replacement might include nursing-initiated pain protocols, automatic discontinuation of Foley catheters within hours postoperatively when certain predetermined criteria are met, and automatic ambulation on postoperative day 1. The Institute for Healthcare Improvement has identified standardization as a first step in developing more reliable systems independent of individual providers or unit assignment. Care maps have been shown to decrease lengths of stay for postsurgical care (knee arthroplasty, transurethral prostate resection, carotid endarterectomy), to decrease postoperative complications (cardiac surgery, femoral neck fracture), to increase physical function and ambulation at discharge (hip fracture), to decrease inpatient mortality (community-acquired pneumonia, congestive heart failure), and to improve pain assessment and end-of-life care (inpatient hospice, acute oncology unit). Each care map or clinical pathway is problem specific and ideally developed around evidence-based care shown to improve outcomes in the vulnerable older adult.

Geriatrician comanagement with surgical services is another promising model in which geriatricians manage the patients’ medical and geriatric issues while the surgeons focus on surgical and perioperative care. Geriatrician–orthopedist comanagement of the patient with hip fracture repair, as well as elective joint replacement, is the most common comanagement model. These services have protocols in place to optimize rapid preoperative assessment, decrease time from admission to surgery, and focus on many of the issues common to the other models above. Most use care maps to standardize care such as thrombosis prophylaxes or time to ambulation. Trials show decreased lengths of stays, decreased postoperative complications, improved mobility, decreased inpatient mortality, and improved nursing and surgeon satisfaction.

Goals of Care

The successful management of the hospitalized older adult will incorporate features of effective models of care described above. A common feature of these models is the recognition that the care plan must be consistent with the patient’s goals of care. Failure to understand a patient’s goals of care is common, and can lead to frustration and dissatisfaction on the parts of patients, family members, and caregivers.

The goals of hospital care should be established upon admission for each patient. For older persons, these can vary widely and may include prolonging survival, relieving specific symptoms, maintaining or regaining ability to walk or care for oneself, getting help taking care of oneself, avoiding institutionalization, being reassured during a frightful experience, and providing comfort and peace while dying. Family members may share these goals but may also have additional goals, such as getting help caring for the patient, facilitating a transition in care from home to long-term care, or being protected from a frightening situation. Physicians and other professionals involved in the care of the patient may share these goals and also aim to achieve quality, efficiency, and patient satisfaction measures for inpatients, reduce hospital costs, and avoid adverse events.

Such discussions may be initiated with open-ended requests, such as: “Different patients have different goals when they are admitted to the hospital. Can you tell me about what you would like us to accomplish while you are in the hospital?” Discussions of goals of care are broader than simply cataloging do-not-resuscitate (DNR) decisions or reviewing options for specific therapeutic interventions. In fact, DNR and other decisions may be ill-informed without discussion of the goals of care. Explicit articulation of goals of care will sometimes identify disagreements or unreasonable expectations, which should be recognized and usually addressed.

Comprehensive Geriatric Assessment

A second feature of these models is the addition of a comprehensive assessment of a patient’s physical, cognitive, psychological, and social functioning to the problem-focused assessment (Table 16–1). The problem-focused assessment will identify and address the reason for admission. The comprehensive assessment of key functional domains will ensure that an appropriate care plan is implemented. Just as the underlying reasons for the hospitalization of an older adult may be multifactorial, the care plan must address these multiple factors.

Functional assessment determines the patient’s ability to walk and to perform basic ADLs (eg, bathing, dressing, transferring from a bed to a chair, using the toilet, self-feeding) both at baseline, before onset of the acute illness, and on admission. For some patients, an unmet need for assistance with ADLs at baseline may be a contributing factor to the hospitalization. Patients who are dependent in an activity of daily living on admission have longer hospitalizations, higher risk for additional ADL dependence at discharge, and higher risk for death on average than otherwise similar patients who are independent in ADL. Patients dependent in ADLs at discharge are at increased risk for nursing home placement, loss of additional ADLs after discharge, and for death during the next year. Past history of falls is also important to elicit on admission and address during the hospitalization and in collaboration with the primary care provider after discharge.

Cognitive and psychological assessment should include assessment of mental status and affect. Among hospitalized older medical patients, ≥20% have dementia, ≥15% are delirious on admission, and another 15% experience delirium during hospitalization. Symptoms of depression are common, and 33% of hospitalized older medical patients have major or minor depression.

Neuropsychiatric assessment begins on meeting the patient. Stop to consider the possibility of dementia, delirium, and depression: They are frequently present but infrequently reported. To whom are you speaking? If you are obtaining the history from a surrogate rather than the patient, cognitive impairment from dementia or delirium or both is likely. Serious cognitive impairment is indicated by an inability to recall any of 3 items; it is largely ruled out by recall of 3 items and ability to draw the face of a clock as in the Mini-Cog. Listen for evidence of any change in mental status or behavior, and watch for signs of impaired thinking, speech, or judgment. The presence of fluctuating mental state, impaired attention, and/or consciousness or disorganized thinking suggests a delirium. Evidence of inattention includes difficulty focusing, being easily distracted, or failure to repeat 5 digits. The Confusion Assessment Method (CAM) is a highly sensitive and specific screening tool for delirium in hospitalized older adults. As a simple screen for depression, ask the patient whether he or she has felt sad, depressed, or hopeless over the last month.

It is critical for the attending physician, along with other members of the interprofessional team, to understand the patient’s social context in order to develop an effective after hospital care plan. Social isolation, loneliness, and lack of social supports are common in hospitalized older adults. This will affect the amount of in-home supportive services, meals and transportation assistance, and assistive devices a patient may require. Any hesitations or concerns should be explored further for evidence of elder neglect or abuse. The prevalence of elder abuse is higher in hospitalized settings (∼14%) than in the general community (∼3% to 4%). Ask about how the patient manages his or her finances to explore for evidence of financial abuse. Concerns about abuse should be discussed with a social worker and reported to the local adult protective services agency.

In addition to completing a functional, cognitive, psychological, and social assessment on every older adult admitted to the hospital, a geriatrics-focused review of systems may identify conditions that are commonly considered geriatric syndromes, including incontinence, falls, sensory impairment, undernutrition, and social isolation. Each of these conditions can and should be addressed specifically. In addition, however, it is important to recognize that frequently 2 or more geriatric syndromes occur synchronously in frail patients, and that the burden of this frailty on patients, families, and professionals is substantial.

Interprofessional Care

The third common feature of many successful models of care for older adults is an interprofessional approach that addresses the multiple factors that may contribute to hospitalization. In most cases, designing and implementing strategies to achieve the goals of care requires the physician’s expertise and the expertise of a team of other experts. For example, consider the situation of an 83-year-old widow with chronic obstructive pulmonary disease (COPD) and mild cognitive impairment who lives alone, has declined over the past month in her ability to take care of her home and her affairs, is admitted with hypoxia and hypercarbia attributed to a COPD exacerbation, and wishes to live in her home until she dies. Although the physician may have the expertise to treat the COPD exacerbation, nursing, social work, and occupational therapy expertise is also required to promote the patient’s independent function at home after discharge.

In general, the treatment of disease should not differ according to age. Treatment should be selected on the basis of the goals of care for a particular patient and on the basis of evidence that a particular treatment regimen will achieve the specified goal.

Older patients may differ from younger patients according to their goals. For example, treatment directed primarily at amelioration of symptoms and dysfunction rather than prolongation of survival may be desired more often by patients in their 90s than by those in their 60s. Also, insofar as these choices are influenced by prognosis, which is determined in part by age, patients should be informed accurately when they desire this information. Nonetheless, the goals of care differ between patients of the same age and should be determined individually.

Evidence of the efficacy of a treatment regimen in achieving a specific goal should be sought. In some situations, treatment efficacy may differ by age. For example, thrombolytic therapy of acute myocardial infarction is less efficacious in prolonging survival in persons age 75 years and older than in younger persons, and acute coronary revascularization may be more efficacious in these patients. Doses of therapies often need to be titrated to reflect renal or hepatic function, which often decline with age. The risk of side effects from many drugs and procedures also increases with age, and these risks should be considered in estimating the net benefit of a specific treatment strategy.

Unfortunately, most evidence about the efficacy of many therapies is based on studies of younger persons, and specific evidence about the efficacy of those therapies in persons age 75 years or older is inadequate. In these situations, it is reasonable to extrapolate from evidence in younger patients, taking into account age-related differences in hepatic and renal function and risks of side effects when deciding on and implementing a specific treatment regimen.

To prevent iatrogenic complications common in hospitalized older adults, additional assessments on admission and throughout the hospital stay are required (Table 16–2).

Functional decline is a feared, but all too common, adverse outcome of hospitalization. Many complications can be prevented through a dedicated effort to maintain mobility in the hospital. Clinicians should set walking expectations early for each patient and assess compliance daily. Although symptoms and fear of injury may limit some patients, most are motivated by avoiding functional decline and simply being asked to walk. Clinicians should also treat pain that may be inhibiting in-hospital walking; ensure assistive devices are available with appropriate rehabilitation therapy training; and remove unnecessary tethers such as bladder and intravenous catheters, oxygen lines, and cardiac monitoring. Unnecessary bladder catheters, in addition to causing iatrogenic infection and limiting mobility, are associated with increased functional decline and mortality after hospital discharge.

In addition, hospitalization provides an opportunity for the assessment and implementation of routine preventive maneuvers in older patients: Maneuvers that should be considered in every older hospitalized patient include:

• Deep venous thrombosis prophylaxis

• Influenza vaccination.

• Pneumococcal vaccination.

• Determination of smoking status and counseling about smoking cessation.

• Screening for alcoholism and seeking counseling when indicated.

• Screening for undernutrition, including vitamin D deficiency

It is increasingly recognized that transitions between care providers and across settings are common and fraught with hazards. Older adults, especially, express confusion regarding self-management after hospitalization. These hazards and confusion have led to a new focus of care called “transitional care” (see Chapter 13, “Transitions and Continuity of Care”). There are numerous interventions aimed at improving the transitional care of older adults leaving the hospital. While these multicomponent interventions differ, they all have several key components in common. All implement strategies to improve patient and caregiver engagement in the process starting at the time of admission. All seek early identification of postdischarge care needs and use interprofessional teams to properly address those needs throughout the hospitalization, as well as after discharge. All invest a considerable amount of time and resources into improving patient understanding about the reasons for admission, what is required to manage their health at discharge, appropriate signs and symptoms that signal a need for early intervention, and who they should contact for questions or help. All give special attention to medication reconciliation, patient instruction, and cross-site communication of medication changes. All also improve communication between inpatient and outpatient clinicians via phone calls and improved discharge summary communication. Table 16–3 is a checklist for improving care at the time of transition from hospital to next site of care.

In addition to the topics common to the interventions above, inpatient clinicians caring for older adults need an understanding of the multiple postdischarge sites of care available for this population. Will the patient require rehabilitation for deconditioning? If so, will the patient meet requirements for intensive rehabilitation hospitals versus skilled nursing facilities (SNFs)? Is there a skilled need that requires home services after discharge or inpatient SNF services, (often this depends on the availability of a caregiver)? Has the patient declined in physical or cognitive function such that 24-hour supervision will be required at discharge? Can 24-hour supervision be done at home or will nursing home placement be required? Is the patient nearing the end-of-life with goals more consistent with hospice care? Should hospice care be arranged prior to discharge? Most patients prefer to stay in their homes as long as possible and good transitional care can help them achieve that goal by optimizing care at home if possible, and putting plans in place to regain and optimize functional status.

Estimating Prognosis for Elders http://www.eprognosis.org

The Hospital Elder Life Program (HELP). http://www.hospitalelderlifeprogram.org/public/public-main.php